thinking outside the box

[gamma6]

one of the benefits of working EMS in texas is that the physician sets the standard of care in allowing what you can and can't do. the physician that we work under, allows us to "to practice medicine" and stray from the COGs a bit.

the COG is a guide line to go by but not one situation is the same, not everyone gets the same treatment all the time, if you can back up why you did something and make it work they are really cool about it. we rarely have to call med control on much. ex: nitro for a hypertensive crisis if you can't get the bp down by other means. understanding the effects that the nitro can have on the negative feedback loop system is a major player in this.

i have not worked in others states and am wondering what the guide lines are like that you have to play by.

 

[VentMedic]

ex: nitro for a hypertensive crisis if you can't get the bp down by other means. understanding the effects that the nitro can have on the negative feedback loop system is a major player in this.

You are talking about for cardiac and not a neuro event, correct?
It can increase the ICP in a neuro event.

Nitroglycerin has vasodilator effect predominantly on the peripheral veins with just a little effect on the arteries. It primarily reduces cardiac oxygen demand by decreasing preload (left ventricular end-diastolic pressure with a slight effect on afterload.

Many of the things that are considered to be "thinking out of the box" are really the "rest of the story". The pharmacology and treatment plans along with the associated pathophysiology offered in the Paramedic programs are very abbreviated. The "out of the box" stuff comes from some advanced clinical guidelines that you might see when on good CCTs, Flight programs or in the hospital.

 

[zmedic]

It's funny, but the closer I get to my MD the less comfortable I think I would be letting medics who were on my license practice outside the guidelines. For one it's my butt, two most of the things that are in the guidelines are there because there is some kind of evidence or common sense that having it done in the field will improve outcomes. So one question is "how often does what a medic tries that isn't in protocols actually help patients?" Sure getting BP down in hypertensive crisis is good, but if you are 5 minutes from the hospital do you need to try things that aren't in the protocols? Is there really a big harm in calling med control the once a month that you want to try something out there? (I'd aruge that if you want to be doing things "out of the box" daily/weekly either someone is getting ahead of themselves or the protocols are too restrictive.

To be clear, if medical control wants to set up local standing orders that's one thing, you need to have a lot of trust in your medics to say "oh, try what you think is best, you don't have to call." Maybe this works in a very small system where med control knows all the medics well and trusts them, but I don't think i'd risk my license on it. Because I can't think of much that a medic would have to do that isn't in protocols but is so urgent that they can't take the 5 minutes to call the hospital.

 

[Lifeguards For Life]

It's funny, but the closer I get to my MD the less comfortable I think I would be letting medics who were on my license practice outside the guidelines. For one it's my butt, two most of the things that are in the guidelines are there because there is some kind of evidence or common sense that having it done in the field will improve outcomes. So one question is "how often does what a medic tries that isn't in protocols actually help patients?" Sure getting BP down in hypertensive crisis is good, but if you are 5 minutes from the hospital do you need to try things that aren't in the protocols? Is there really a big harm in calling med control the once a month that you want to try something out there? (I'd aruge that if you want to be doing things "out of the box" daily/weekly either someone is getting ahead of themselves or the protocols are too restrictive.

To be clear, if medical control wants to set up local standing orders that's one thing, you need to have a lot of trust in your medics to say "oh, try what you think is best, you don't have to call." Maybe this works in a very small system where med control knows all the medics well and trusts them, but I don't think i'd risk my license on it. Because I can't think of much that a medic would have to do that isn't in protocols but is so urgent that they can't take the 5 minutes to call the hospital.

how close are you to getting your MD?

 

[gamma6]

you know what? screw it, never mind...i asked a simple question about your COGs in your area.....you guys wanna tear apart every little thing. if you don't know why you shouldn't give nitro repeatedly during a htn crisis, then........it was an example why we would call med control...............................a post was put up earlier about medics giving 1:1000 epi IV.....uh ya really!!!! that completely seals the deal why your physicians don't trust the medics under them.

we here are taught to think outside the box and not be cookbook medics....


just saying......

 

[MrBrown]

one of the benefits of working EMS in texas is that the physician sets the standard of care in allowing what you can and can't do. the physician that we work under, allows us to "to practice medicine" and stray from the COGs a bit.

In Texas (having seen this first hand) the Medical Director is basically omnipotent they have absolute power and can do what they please.

Texas is also probably the state where one requires the least amount of training to become a Paramedic, 625 hours.

I am not sure the two go hand in hand together!

Here in Kiwi we don't have any "medical control", no online orders and we have near total autonomy and can recommend non transport. While this gives the AOs here a very flexible approach to clinical care and transport we also have the education to back it up and in the future, we'll have even more education.

As far as GTN to drop blood pressure, are you talking about oral or intravenous nitrates? I am no expert on the subject but I understand that oral GTN can drop blood pressure quite radically (you don't want to reduce it by more than 1/3) and in hospital often invasive measuring is used which ambo's don't have.

 

[MrBrown]

you know what? screw it, never mind...i asked a simple question about your COGs in your area.....you guys wanna tear apart every little thing. if you don't know why you shouldn't give nitro repeatedly during a htn crisis, then........it was an example why we would call med control...............................a post was put up earlier about medics giving 1:1000 epi IV.....uh ya really!!!! that completely seals the deal why your physicians don't trust the medics under them.

we here are taught to think outside the box and not be cookbook medics....


just saying......

Dude, chillax.

You don't seem to get that .....

Australia: Three year Bachelors Degree
New Zealand: Diploma (BLS) or Bachelors Degree or higher (ILS/ALS)
UK: Three year Bachelors Degree
Most of Europe: RN or Physician
Ontario: Two years (BLS) or three years (ALS)
Oregon: Two year Degree
Medic One: Some crazy amount of hours, like 3,000

Meanwhile .... most of the US (and I've seen this first hand) requires around 1,000 hours of training, using a curricula that was written over a decade ago and that requires no interaction whatsoever with the College/University system.

A program my friend went through was described as a vocational, non-college credit, non degree awarding clock hour program. Now that's just scary.

Another medic friend in California says his job is to "save people from fire department paramedics".

I could probably pass the NREMT-Paramedic test tomorrow provided I did a little revision and the hardest part would probably be how to program my GPS to get to the PearsonVue Centre!

It's not that we are having a go at you in particular it's just lets face it .... (speaking generally) the scope of practice and autonomy probably does not match the education and this creates adverse clinical risk and it's unbeknown to the providers because they simply didn't learn enough to recognise it.

 

[medichopeful]

Texas is also probably the state where one requires the least amount of training to become a Paramedic, 625 hours.

h34r:

 

[JPINFV]

Another medic friend in California says his job is to "save people from fire department paramedics".

It's rare to save a fire medic from delivering bad care in California. That's because fire medics avoid providing patient care like the plague to begin with.

 

[Scott33]

I could probably pass the NREMT-Paramedic test tomorrow provided I did a little revision and the hardest part would probably be how to program my GPS to get to the PearsonVue Centre!

:lol::lol::lol::lol::lol:

 

[EMSLaw]

I could probably pass the NREMT-Paramedic test tomorrow provided I did a little revision and the hardest part would probably be how to program my GPS to get to the PearsonVue Centre!

Especially if you spelt it "Centre." And don't forget, your additional fancy book learnin' might actually make the questions more difficult. It would be like if I took a certificate-level business law exam, "Wait. None of these answers are right. And I'm missing facts X, Y, and Z! What the @#$!!!"

Seriously, though, well said in general.

 

[Scott33]

you know what? screw it, never mind...i asked a simple question about your COGs in your area.....you guys wanna tear apart every little thing.

Not necessarily, but there is usually a legitimate counter argument to posts such as this; one which Vent already gave.

a post was put up earlier about medics giving 1:1000 epi IV.....uh ya really!!!! that completely seals the deal why your physicians don't trust the medics under them.

Push or Drip? My NYC protocols have an MC option for an Epi drip for symptomatic bradycardia (seen below), and also a standing order epi 1:10,000 drip and / or MC epi 1:1,000 drip for Anaphylaxis:

"Administer Epinephrine 2 ug/min, IV/Saline Lock drip. Prepare infusion by adding 1 mg of Epinephrine (1 ml of a 1:1,000 solution) to 250 ml of Normal Saline (0.9% NS) (1 ug/min = 15 ml/hr = 15 gtts/min). If there is insufficient improvement in hemodynamic status, the infusion may be increased until the desired therapeutic effects are achieved or adverse affects appear. (Maximum dosage is 10 ug/min, IV/Saline Lock drip.)"

http://www.nycremsco.org/images/articlesserver/05-ALS Protocols July 2009 v070109a.pdf

we here are taught to think outside the box and not be cookbook medics....

Excellent. But by your own admission you are just starting out as a medic, so I would be cautious about trying to run before you can walk.